In patients with rheumatoid arthritis (RA) receiving treatment with glucocorticoids (GCs) and concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), GC tapering and discontinuation may be feasible with favorable control of disease activity.
Although GCs are considered an effective short-term treatment for RA, long-term use is associated with substantial safety concerns. The 2019 European Alliance of Associations for Rheumatology (EULAR) guidelines recommend that GCs be discontinued as soon as clinically feasible, typically within 3 months of initiation.
To assess the clinical trajectory of GC cessation in patients with RA, study authors extracted data from a longitudinal real-world cohort study conducted in Beijing, China. The Treat-to-Target in RA (TARRA) cohort included patients with RA between 2009 and 2019. Baseline demographic, clinical, and laboratory features were collected, following which patients were prospectively followed up with for changes in clinical features until 2020.
The current analysis included patients with RA who received concomitant treatment with GCs and csDMARDs. Rate of GC discontinuation was analyzed using Kaplan-Meier curves. The primary study outcome was a disease flare during tapering, defined by an increase in disease activity; a re-initiation of GCs; an addition or increase in DMARDs; or a flare diagnosis by the treating rheumatologist. Prescribed GC dose was converted to prednisolone equivalent dose for all study calculations.
Data from 207 patients with RA were included in the analysis, among whom 124 discontinued GCs during follow-up. Mean age at GC initiation was 55.9±14.5 years; 171 (82.6%) patients were women; and 110 (53.1%) were DMARD-naive at baseline. Median follow-up time was 38.6 months. Median baseline prednisolone dose was 10.0 mg/day, which decreased by an average of 50% during the first 6 months of follow-up. Median time to full cessation was 27 months.
According to the Kaplan-Meier method, the cumulative probabilities of GC discontinuation were 9.7%, 26.6%, 48.0%, and 58.6% at 6 months, 1 year, 2 years, and 3 years of follow-up, respectively. Among the 110 patients who were DMARD-naive at baseline, the cumulative probabilities of GC discontinuation were 12.7%, 30.0%, 50.9%, and 60.5% at 6 months, 1 year, 2 years, and 3 years of follow-up, respectively. Median time to GC cessation was 24 months in this subcohort of patients. Among the 124 patients who discontinued GCs, approximately half were in clinical remission at cessation; 91 of 115 (79.1%) patients remained flare-free 6 months after GC withdrawal.
These data support the feasibility of GC tapering in patients receiving csDMARDs for RA. The majority of patients were able to achieve and maintain clinical remission during the tapering period.
Study limitations included the single site and small patient cohort. Further research is necessary to elucidate the clinical trajectories of GC discontinuation.
“GC is feasibly discontinued in real-life setting when disease activity is [favorable], mostly without short-term flare, in patients who newly start GC with concomitant csDMARDs,” the study authors wrote. “But the withdrawal time is far from reaching the recommended time frame, suggesting the gap between real-world practice and current guidelines.”
Xie W, Huang H, Li G, et al. Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020. Ann Rheum Dis. Published online July 13, 2021. doi:10.1136/annrheumdis-2021-220112